**Author details**

greater diameter than the widest measured carotid diameter into which the stent will be deployed, typically at the bifurcation [44]. Because the carotid artery bulb is typically signifi‐ cantly larger than the cervical segment of the ICA, some carotid stents are designed with a tapered diameter, such as 6mm diameter distally and 8mm diameter proximally, to accom‐ modate for this and to prevent the stent from being significantly oversized distally for an appropriately selected diameter for the proximal ICA. The appropriately selected stent is then positioned across the ICA stenosis, taking care to avoid placement of the distal end of the stent at a curved segment of the ICA, as some patients may have a relatively tortuous ICA course. This will help to avoid kinking of the stent or occlusion or dissection of the ICA. After the stent is deployed across the lesion, a DSA run is performed to confirm the location of the stent and to evaluate for residual stenosis. An appropriately selected balloon is then chosen and positioned along the center of the greatest stenosis. At the time of balloon inflation, care should be taken to watch the heart rate and blood pressure, as stretching of the carotid bulb could result in significant bradycardia or asystole. The balloon should be inflated only a few seconds, and should not remain inflated for more than 10-20 seconds during the initial post-stent angioplasty. The balloon may be left inflated longer as long as the patient remains asympto‐ matic with the occlusion of carotid blood flow, but this should not be done for longer than 1-2 minutes at a time. The distal protection device is then recovered, taking care to avoid inad‐ vertently snagging on the stent tines and potentially dislodging the position of the stent. The femoral arteriotomy access site is then closed and the patient should remain flat with the accessed leg straight for at least 1 hour after placement of an arterial closure device, or for 4-6 hours with a sandbag or clamp to hold pressure on the femoral arteriotomy site if no closure

216 Carotid Artery Disease - From Bench to Bedside and Beyond

The NASCET evidence supports the treatment of symptomatic hemodynamically significant carotid artery stenosis of ≥50% by NASCET criteria for men, and ≥70% for women. The only trial that advocates surgical intervention for asymptomatic carotid stenosis is the ACAS trial, and surgical intervention for asymptomatic carotid artery stenosis ≥60% was supported, but other trials would support best medical management because of the very low incidence of ipsilateral stroke from asymptomatic carotid stenosis, regardless of the degree of stenosis. Carotid endarterectomy remains the gold standard treatment for patients who are medically stable enough to tolerate the surgery. Carotid angioplasty without stent placement has a high rate of recurrence of stenosis, and therefore with current devices available, patients in whom endovascular treatment has been chosen for carotid stenosis should be treated with stent placement and should be pre-medicated with anti-platelet agents such as aspirin and clopi‐ dogrel, or alternative drugs such as prasugrel in clopidogrel non-responder patients. These medications should be continued for at least 3 months post-procedurally and the low dose

device is used.

**9. Conclusions**

(81mg) aspirin should be continued indefinitely.

David J. Padalino and Eric M. Deshaies\*

\*Address all correspondence to: deshaiee@upstate.edu

Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, USA
